MEDICARE: MS. DEBRA G. SIDDALL DEVELOPMENTAL THERAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1619195062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBRA G. SIDDALL DEVELOPMENTAL THERAP

Provider Business Mailing Address
First Line	:	4129 177TH ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-4859
Country	:	US
Telephone Number	:	708-289-8730
Fax Number	:

Provider Business Practice Location Address
First Line	:	4129 177TH ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-4859
Country	:	US
Telephone Number	:	708-289-8730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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